Utilization Review Nurse

WVU Medicine; United States; À distance; USD 75 000 - 95 000; Plein temps

Résumé du poste

PHH Peak Health Holdings seeks a skilled Registered Nurse with 3 years of healthcare clinical experience to support utilization and care management activities. The role involves building and implementing review processes, ensuring outcome-focused interventions, and collaborating with medical directors to improve member care.

The position requires a current RN license (state or eNLC) and offers a full-time, on-site arrangement in the United States. Occasional weekend/holiday work may be required.

Qualifications

• Current Registered Nurse license (RN) in the state of practice or multi-state license via eNLC.
• Three (3) years of healthcare clinical experience.

Responsabilités

• Assists with building and implementing care management review processes (Prior Authorization, Predetermination, Concurrent and Retrospective reviews) per standards.
• Develops and implements care management reviews according to criteria and policies.
• Ensures interventions maximize member health outcomes.
• Supports Peer-to-Peer Review with Medical Directors to improve services.
• Educates stakeholders to improve processes and build network relationships.
• Collaborates with medical management to identify members needing coaching/case management.
• Works with data to understand outcomes and identify improvement opportunities.
• Committed to lifelong learning and continuous process improvement in Utilization Management.

Connaissances

InterQual/Milliman Guidelines

Regulatory knowledge

Written and verbal communication

Problem solving

Attention to detail

MS Office

Formation

Registered Nurse license (RN)

BSN or ASN; BSN completion within 3 years

Outils

Microsoft Office

Description du poste

MINIMUM QUALIFICATIONS** : :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

EXPERIENCE:

1. Medical Management for Medicare and/or Medicaid populations.
2. Utilization Management experience.

CORE DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.
6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
7. Understands the data that is collected within the position, and work with other team members on improving outcomes.
8. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

PHYSICAL REQUIREMENTS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.
4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

Attention to detail.

1. Proficiency with Microsoft Office.

Additional Job Description:

This role may require occasional weekend and holiday work.

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PHH Medical Management